WORKING
P A P E R
Assessing Health and
Health Care in the District
of Columbia
Phase 2 Report
RAND AUTHORS:
NICOLE LURIE, CAROLE ROAN GRESENZ,
JANICE C. BLANCHARD, ANITA CHANDRA,
BARBARA O. WYNN,
KRISTY GONZALEZ MORGANTI, TEAGUE RUDER,
AND AMBER PRICE
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GEORGE WASHINGTON UNIVERSITY
AUTHORS:
DONNA SICKLER, BONNIE NORTON,
JANICE C. BLANCHARD, KAREN JONES,
MARSHA REGENSTEIN, AND BRUCE SIEGEL
WR-579
June 2008
EXECUTIVE SUMMARY
As a result of the recent settlement of tobacco litigation, the District of Columbia has more than
$200 million available to invest in the health of the city’s residents. A Health Care Task Force,
convened in 2006 by then-Mayor Anthony Williams, considered alternative ways to invest the
available funds. The Task Force crafted several options that included investment in additional or
improved hospital capacity, ambulatory care, and health care system improvement, but agreed
that research was needed before final investment decisions could be made. The District
contracted with the RAND Corporation to study health and the health care delivery system in the
District. The goals of RAND’s evaluation are to:
1) Conduct a comprehensive health needs assessment for Washington D.C.;
2) Assess the quality and accessibility of the District’s health care delivery system for
individuals with urgent or emergent medical needs; and,
3) Use information from those assessments to identify and assess various policy options for
improving the health care delivery system.
An interim report (http://www.rand.org/pubs/working_papers/WR534/) summarizes findings
related to the first two goals. Since the release of the interim report, we conducted additional
quantitative and qualitative analyses. Specifically, we:
x
Conducted focus groups with community residents.
x
Interviewed and convened focus groups with District health care providers.
x
Synthesized information describing the health care safety net in the District.
x
Conducted additional analyses of Medicaid and Alliance managed care claims data, hospital
discharge data, and data on Medicaid provider capacity from the Medicaid Assistance
Administration (MAA).
x
Surveyed each of the eight acute care hospitals in the District of Columbia to get additional
information about hospital and emergency department patient flow and staffing.
x
Analyzed data from D.C. Fire and Emergency Medical Services (FEMS), including six years
of computer-aided dispatch (CAD) data and data from electronic run sheets for a two-month
period in 2006.
x
Obtained and analyzed information about the times at which patients first present to
emergency departments.
In addition, we visited six clinics and discussed our findings and with a wide array of
stakeholders, including representatives from DCHA, staff at individual hospitals and clinics,
representatives from DCPCA, and the RAND Advisory Committee appointed by the Mayor and
City Council. Findings are presented in the body of the full report.
The majority of the report addresses the third goal. Legislation passed in December 2006
allocated some of the tobacco settlement funds, including $20 million for cancer prevention, $10
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million for anti-smoking efforts, $10 million for chronic disease treatment, $6 million for
establishing a regional health information exchange, and $2 million to buy new ambulances.
Legislation passed in 2007 further authorized the use of $79 million for a public/private
partnership between the District and Specialty Hospitals of America for the revitalization of
Greater Southeast Community Hospital (though some of those funds are in the form of a loan).
We provide recommendations for the allocation of the remaining funds, totaling approximately
$135 million, which by legislation are limited to capital expenditures.
ES.1 Recommendation
Based on our analyses, we articulate (1) specific recommendations for the expenditure of tobacco
settlement funds; (2) additional policies critical to the success of the capital investments; (3)
complementary policies needed to improve ambulatory care; (4) recommendations relating to
emergency medical services; and (5) recommendations regarding the allocation levels of capital
investments.
Recommendations for Investing Tobacco Settlement Funds
(1) Use tobacco settlement funds to expand the capacity and improve the physical space of
community health centers. 1
(1.1) Target expanding primary care capacity in community health centers (CHCs) by
roughly 200,000 visits.
(1.2)
Invest in CHCs that expand capacity in high-need locations.
(1.3) Invest in CHCs that establish and commit to maintaining urgent care capacity
(including after-hours and weekend capacity) in at least two high-need locations.
(1.4) Prioritize expansions to CHCs that would increase the availability of specialty
care through plans for additional exam room space, investments in equipment to allow for
specialty care services, and planned personnel arrangements with local hospitals.
(1.5) To the extent possible, invest in expansions that leverage funding from other
sources.
(2) Use tobacco settlement funds to support greater adoption of health information technology.
(2.1) Subsidize the adoption of electronic health records by hospitals and by providers
who serve a substantial number of individuals who are enrolled in Medicaid or the
Alliance or who are uninsured.
(2.2)
Invest in sustaining the regional health information organization (RHIO).
(2.3)
Consider investments in other promising health technologies.
(3) Use tobacco settlement funds to invest in establishing an information clearinghouse for
provider availability.
1
By community health center (CHC) we mean any ambulatory care facility that provides first contact, coordinated,
comprehensive, continuous outpatient care for all regardless of their ability to pay. We do not restrict our definition
of a CHC to federally qualified health centers or look-alikes.
v
(4) Use tobacco settlement funds for implementing and evaluating interventions and
programs to improve the accessibility and quality of care; for planning and initial
implementation of new data collection; and for additional evaluations of health and health
care in the District.
(5) Use tobacco settlement funds to pay for projects that move ambulatory health care facilities
closer to evidence-based design.
(6) Invest tobacco settlement funds in diversion reduction strategies including a collaborative
and a “dashboard” with real-time information about diversion status and bed availability across
hospitals.
(7) Delay allocation of a portion of tobacco settlement until an assessment of needs for mental
health and dental care is complete, and to pay for ongoing investments in health care service
delivery improvement.
Additional Policies to Ensure the Success of Capital Investments to Expand Capacity
x
Modify Medicaid and Alliance reimbursement for primary care and outpatient specialty care
providers.
x
Enhance financial incentives for primary and specialty care providers who serve the
underserved.
x
Ensure the availability and affordability of medical malpractice coverage for specialists
serving Medicaid/Alliance enrollees and the uninsured.
Complementary Policies for Improving Ambulatory Care
x
Focus private and public purchasers on purchasing quality health care.
x
Re-enfranchise District patients in the health care delivery system.
x
Promote health education and facilitate health care navigation.
x
Improve coordination of care between hospitals and physicians and between primary care
and specialty care physicians.
x
Improve ongoing data collection and monitoring of health and health care in the District,
including data on the health and health care of children.
Recommendations for Improving Emergency Services
x
Develop a robust system to continuously assess the quality of emergency services.
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x
Incentivize D.C. hospitals and D.C. FEMS to work together in a concerted effort to reduce
hospital diversion and drop times.2
x
Develop a system to track diversion and factors related to it.
x
Create a city-wide diversion policy.
x
Regionalize services to insure that patients are transported to hospitals that can meet their
emergent needs.
Recommendations for Funding Allocation Levels
Table ES.1 below summarizes the recommended strategy for allocation of tobacco settlement
funds.
Table ES.1: Summary of Recommended Allocation Strategy
Recommendation
1
Expenditure
Expansion of primary and urgent care
CHC capacity
Electronic health record adoption,
RHIO, other health information
technologies
Information clearinghouse
Pilots, data collection, and evaluation
Evidence-based design for ambulatory
care
ED collaborative and dashboard
Reserve for additional investments,
including mental health, oral health
Total
2
3
4
5
6
7
Level of Funding
(approximate,
in millions)*
$90
$24
$0.5
$8
$2.5
$2
$7.5
$135
*Figures are upper bounds where a range in the text is specified.
ES.2 Gaps in Knowledge
Substantial gaps exist in what we know about the health of District residents and their health
care. Filling these gaps will better enable the District to determine whether and how to invest in
additional components of care for District residents. Our recommendations include the
allocation of funds to ongoing evaluation activities. In what follows, we summarize a number of
gaps in knowledge that largely reflect gaps in the data available.
x
Little is known about children’s health status and access to care.
2
Diversion is when a hospital can only accept the sickest “priority 1” patients. Drop time is the amount of time it
takes for EMS providers and hospital staff to transfer a patient from pre-hospital to hospital care.
vii
x
Available information about insurance status among adults in the District is inadequate.
x
Little is known about the quality of emergency medical services in D.C.
x
Available data on mental health status and mental health and substance abuse service needs
and use are extremely limited.
x
Provider supply could be measured with more precision if reliable data on practice time in
the District and population served, by type of insurance, were available.
x
Differences in data formats and availability of Medicaid and Alliance data from managed
care organizations make it less useful than it could be.
x
The lack of timely analysis of data with which to monitor the health of the District should be
addressed.
x
We need clearer understanding about the role of private office-based providers in the
delivery of care to Medicaid and Alliance enrollees and for the uninsured.
ES.3 Conclusion
The targeted infusion of tobacco settlement funds has the potential to improve considerably the
robustness of the District’s health care system; and especially so if these investments are made in
conjunction with auxiliary and complementary policies to increase the capacity, quality, and
accessibility of health care services in the District, and activities to provide ongoing data and
analysis to monitor progress.
However, “fixing” the health care delivery system in the District cannot be accomplished with
one-time policies or investments. Rather, the District needs to maintain a long-term vision for
the future of the health of District residents, and commensurate with that, to devote resources to
systematically tracking health and health care outcomes among residents on a consistent basis.
That effort must begin with the new investments that will be made with tobacco settlement
funds.
It also bears repeating that the health of a population is the product of many factors. Our focus in
this report on the health care delivery system is not meant to understate the importance of other
factors on health outcomes. Systemic factors other than access to health care that give root to
poor health outcomes in the city require additional, ongoing, and concentrated attention. These
include the social environment (family structure, education, employment, crime), physical
environment (air quality, water quality, access to healthy food, safe environments for physical
activity), and the prosperity of District residents.
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